TMPPM 2010 >3.4.3 Prior Authorization and Documentation Requirements

3.4.3 Prior Authorization and Documentation Requirements

A request for prior authorization must include documentation from the provider that supports the medical necessity of the service.

The initial therapy request must include the following:

•A Request for Initial Outpatient Therapy (Form TP-1) that has been signed and dated by the therapist and physician.

•A copy of the current evaluation that has been signed and dated by the therapist.

•Documentation that indicates the treatment goals.

•Documentation that indicates the anticipated measurable progress toward goals.

•Documentation that explains the client's gross or fine motor delays or expressive or receptive delays in years or months compared to chronological age.

The extension of the therapy request must include the following:

•A Request for Extension of Outpatient Therapy (Form TP-2) signed and dated by the therapist and physician.

•A summary statement of measurable progress made during the treatment period.

•Documentation indicating new treatment goals.

•Documentation indicating anticipated measurable progress for the next treatment period.

All physician and provider signatures on the TP-1 and TP-2 forms, physician orders, and other documentation must be current, unaltered, original, handwritten, and dated. Computerized or stamped signatures and dates are not accepted.

Refer to: Form CH.12, "Request for Initial Outpatient Therapy (Form TP-1)" in Section 8, "Forms," of this handbook.

Form CH.13, "Request for Extension of Outpatient Therapy (Form TP-2) (2 Pages)" in Section 8, "Forms," of this handbook.

If a provider discontinues therapy with a client and a new provider begins therapy during an existing authorization period, a new evaluation must be submitted. Prior authorization is mandatory and is not a guarantee of payment. Providers must adhere to filing guidelines for payment consideration.